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We list and discuss all "blunders" at our monthly audit meeting (it is our first standing item). This includes both situations where an incorrect result has been issued (for wha tever reason) as well as "near misses" where a member of staff feels that things went wrong but internal checks etc prevented the error going out. i recommend this policy (which can only apply in a no-blame culture) as the single best way of reducing these errors and introducing changes that help to minimise them. For example we recently had a problem with two samples and two request forms submitted simultaneously from a husband and wife (same surname, address and GP) where the two forms arived stapled together making it difficult to spot the different forename. It can be helpful constructive and supportive to staff for these problems to be openly discussed and documented. The data is part of our confidential audit data for internal consumption only. We have no plans to release it to anyone else. I would be interested in more information about the "requirement" under clinical governance that "mistakes should be reported to the patient concerned". Surely that cannot apply to errors picked up within the laboratory? What do others do? James Falconer Smith %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%